Acupuncture Still Doesn’t Work
Needles are not an effective cure for a painful back
Acupuncture has everything that a sham medicine needs to succeed. It’s got the wonderful mystery of the Far East, it’s been around for thousands of years, and it’s hard to conduct rigorous trials on it because you can’t blind people to the fact that needles are going in to their skin.
There’s not much evidence that acupuncture is anything other than an expensive waste of time. Large, well-done studies are scarce, and the studies that do tend to get done are of such poor methodological quality (i.e. they suck) that it’s virtually impossible to conclude anything at all from them.
This is no surprise, because there’s no reason to believe that acupuncture could do anything in the first place. Sticking needles into your skin might have been a treatment for thousands of years, but so has fire-therapy, which is exactly what it sounds like and exactly as effective as you’d imagine being set on fire to cure disease would be.
So why has there been a bunch of yelling about acupuncture being used to treat pain in emergency departments?
The news headlines have all been based off a shiny new study that was done at a number of Australian hospitals. The researchers took 500 people who attended emergency departments complaining of back pain, migraines, or ankle sprain, and divided them into three groups: acupuncture, acupuncture+pain meds, or just pain meds. After one hour, they checked to see if the people had had a significant reduction in their pain, and if not the people were given rescue therapy which is basically just more treatment.
This was a type of research called a non-inferiority study — basically, you know that one treatment works so you try and prove that another treatment is not worse than it. In this case, the researchers were checking to see if acupuncture managed pain as well as traditional first-line medications like paracetamol and ibuprofen.
At first glance it looks like the study was a resounding success, particularly if you read The Conversation piece written by the lead author. The study found that acupuncture performed not worse than traditional therapy for ankle sprains and back pain, although it did perform worse for migraines.
Still, 2 out of 3 isn’t bad, particularly when you are testing the medical equivalent of the Emperor’s New Clothes.
And 80% of all patients reported that they were happy with the treatment! That must mean that it’s effective, right?
Sadly for all those who love magic, not quite.
The first thing that virtually no one reported on was that this paper didn’t so much prove that acupuncture worked as that none of the treatments for these types of pain in ED were effective.
To quote the authors:
none of the therapeutic strategies used provided optimal analgesia within one hour of presentation.
Only about one seventh of the people who came into ED for pain relief actually had a clinically significant reduction in their pain after one hour. That’s really not a high proportion.
Something that most people also missed out was that patients didn’t actually like acupuncture as much, at least at first. At the one-hour mark, patients in the acupuncture-only group were ~10% more likely to report that they wouldn’t try this treatment again. It was only at the 2-day follow up that it evened out to 80% for all groups.
Another thing no one noticed was that acupuncture patients received significantly more rescue therapy. Almost twice as much, in fact. In absolute terms, about 10% more at every stage of the trial.
Here we have to talk about blinding. It’s a well-known phenomenon in medical research that if patients and doctors know who is having what intervention, it biases the results. If I know which treatments I am giving you, I will subconsciously bias the results in favor of the treatment I prefer, and if you are receiving the treatment you will likely do the same if you think it should be working. This makes treatments look more effective than they are, which is a problem.
This makes it really difficult to study acupuncture, because it’s basically impossible to blind people to the fact that they are giving or receiving acupuncture, which means that everyone who was being pricked knew which arm of the study they were in. And this is important, because it’s easy to imagine that if a nice researcher who’s just spent 20 mins needling you asks you if you’re in less pain, you might say yes because you feel bad, or because you know you should be and maybe you are a little who knows?
But even if you say you are in less pain, there’s an objective way to see if you actually are. If you ask for more pain treatment, you are probably still in quite a bit of agony. So the fact that people who had acupuncture were twice as likely to need more pain management indicates that acupuncture was almost certainly significantly less useful in managing pain.
Acupuncture isn’t sounding so rosy now, is it?
It gets worse.
acupuncture was almost certainly significantly less useful in managing pain
Here we get to the really sticky part of the equation. You see, managing acute pain is not easy. Acute back pain in particular is not very well treated with drugs — paracetamol used to be the primary first-line treatment until a recent study called into question its usefulness. Non-steroidal anti-inflammatory drugs like ibuprofen are also used, and although they are effective they only help a little bit.
Bottom line: when it comes to acute back pain, drugs aren’t that great a treatment. The same drugs that acupuncture is supposedly not inferior to.
Non-inferiority is only a good thing when you’re as good as something that works.
So not only was acupuncture arguably worse, because the acupuncture patients needed more rescue treatments, but the thing it was worse than isn’t even a great treatment anyway!
And here we are again, at the same old story. A study with uninteresting and insignificant findings being paraded as the new big story because people can’t be bothered to actually read beyond a press release.
Acupuncture works no better than placebo. This has been shown time and again in studies from all over the world. There’s no reason to believe that it should work, and when you test it with robust evidence, it doesn’t.
The new, amazing evidence proves nothing more than that acupuncture is probably worse than our current mediocre treatments for acute pain. There’s certainly no reason to believe that it should be used in an emergency department alongside traditional pain management.
Does it make a good story? Not really.
But it’s what the evidence suggests.